Provider Demographics
NPI:1164007282
Name:VACCA, TAYLOR KRISTINE (MA, BS)
Entity Type:Individual
Prefix:MS
First Name:TAYLOR
Middle Name:KRISTINE
Last Name:VACCA
Suffix:
Gender:F
Credentials:MA, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10729 TOWN SQUARE DR NE STE 120
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-7923
Mailing Address - Country:US
Mailing Address - Phone:763-343-9010
Mailing Address - Fax:763-343-9011
Practice Address - Street 1:10729 TOWN SQUARE DR NE STE 120
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-7923
Practice Address - Country:US
Practice Address - Phone:763-343-9010
Practice Address - Fax:763-343-9011
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program